Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Nursing Process & Clinical Judgment —
Clinical decision-making and the nursing process
Question Stem: A 58-year-old postoperative patient shows
new-onset confusion and a respiratory rate of 10/min. Which
nursing action best demonstrates clinical judgment as the first
step in the nursing process?
A. Administer the prescribed opioid antagonist.
B. Perform a focused assessment of oxygenation and pain.
C. Call the surgeon to report the change in mental status.
D. Document the findings and plan to reassess in 1 hour.
Correct Answer: B
Rationales:
• Correct (B): A focused assessment of oxygenation and pain
is the appropriate first step to gather data and prioritize
, problems (ADPIE), because confusion with low RR suggests
hypoxia or oversedation.
• A: Administering an opioid antagonist before assessment
risks incorrect intervention; you must identify cause first.
• C: Reporting is important but should follow immediate
assessment and stabilization measures.
• D: Waiting to reassess delays urgent care and may risk
patient safety.
Teaching Point: Assess first to identify immediate threats before
intervening.
Citation: Ignatavicius et al., 2024, Ch. 1: Nursing Process &
Clinical Judgment
2
Reference: Ch. 1: Patient Safety & Risk Reduction —
Prioritization and safety
Question Stem: During shift report, a nurse receives
assignments: (1) a postoperative patient with new hypotension,
(2) a stable patient needing discharge teaching, (3) a patient
requesting pain medication, and (4) a patient with an IV pump
alarm. Which should be seen first?
A. The stable patient for discharge teaching.
B. The patient requesting pain medication.
,C. The patient with the IV pump alarm.
D. The postoperative patient with new hypotension.
Correct Answer: D
Rationales:
• Correct (D): New hypotension after surgery suggests
potential hemorrhage or shock — an immediate life-
threatening issue requiring rapid assessment and
intervention.
• A: Discharge teaching is important but nonurgent
compared with hemodynamic instability.
• B: Pain management is urgent but secondary to potential
circulatory collapse.
• C: An IV pump alarm may indicate a problem but not
necessarily life-threatening; assessment follows
hemodynamic issues.
Teaching Point: Prioritize threats to airway, breathing,
circulation first.
Citation: Ignatavicius et al., 2024, Ch. 1: Patient Safety & Risk
Reduction
3
Reference: Ch. 1: Delegation & Supervision — Delegation
principles for RNs
, Question Stem: An RN is delegating tasks to a licensed practical
nurse (LPN) and a nursing assistant (NA) on a medical-surgical
unit. Which task is appropriate to delegate to the LPN?
A. Administering enteral feedings through a newly placed
feeding tube.
B. Performing initial admission assessment for a patient with
chest pain.
C. Reinforcing teaching about a new warfarin prescription.
D. Assessing and documenting neurovascular status of a
splinted limb.
Correct Answer: D
Rationales:
• Correct (D): LPNs with appropriate competency can
perform focused ongoing assessments like neurovascular
checks and document findings under RN supervision.
• A: Administration through a newly placed feeding tube
requires RN knowledge for verification and potential
complications.
• B: Initial admission assessment including triage for chest
pain requires RN assessment/clinical judgment.
• C: Reinforcing new medication teaching is within RN scope
due to teaching complexity and medication safety.
Teaching Point: Delegate tasks based on scope, competency,
and patient complexity.
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Nursing Process & Clinical Judgment —
Clinical decision-making and the nursing process
Question Stem: A 58-year-old postoperative patient shows
new-onset confusion and a respiratory rate of 10/min. Which
nursing action best demonstrates clinical judgment as the first
step in the nursing process?
A. Administer the prescribed opioid antagonist.
B. Perform a focused assessment of oxygenation and pain.
C. Call the surgeon to report the change in mental status.
D. Document the findings and plan to reassess in 1 hour.
Correct Answer: B
Rationales:
• Correct (B): A focused assessment of oxygenation and pain
is the appropriate first step to gather data and prioritize
, problems (ADPIE), because confusion with low RR suggests
hypoxia or oversedation.
• A: Administering an opioid antagonist before assessment
risks incorrect intervention; you must identify cause first.
• C: Reporting is important but should follow immediate
assessment and stabilization measures.
• D: Waiting to reassess delays urgent care and may risk
patient safety.
Teaching Point: Assess first to identify immediate threats before
intervening.
Citation: Ignatavicius et al., 2024, Ch. 1: Nursing Process &
Clinical Judgment
2
Reference: Ch. 1: Patient Safety & Risk Reduction —
Prioritization and safety
Question Stem: During shift report, a nurse receives
assignments: (1) a postoperative patient with new hypotension,
(2) a stable patient needing discharge teaching, (3) a patient
requesting pain medication, and (4) a patient with an IV pump
alarm. Which should be seen first?
A. The stable patient for discharge teaching.
B. The patient requesting pain medication.
,C. The patient with the IV pump alarm.
D. The postoperative patient with new hypotension.
Correct Answer: D
Rationales:
• Correct (D): New hypotension after surgery suggests
potential hemorrhage or shock — an immediate life-
threatening issue requiring rapid assessment and
intervention.
• A: Discharge teaching is important but nonurgent
compared with hemodynamic instability.
• B: Pain management is urgent but secondary to potential
circulatory collapse.
• C: An IV pump alarm may indicate a problem but not
necessarily life-threatening; assessment follows
hemodynamic issues.
Teaching Point: Prioritize threats to airway, breathing,
circulation first.
Citation: Ignatavicius et al., 2024, Ch. 1: Patient Safety & Risk
Reduction
3
Reference: Ch. 1: Delegation & Supervision — Delegation
principles for RNs
, Question Stem: An RN is delegating tasks to a licensed practical
nurse (LPN) and a nursing assistant (NA) on a medical-surgical
unit. Which task is appropriate to delegate to the LPN?
A. Administering enteral feedings through a newly placed
feeding tube.
B. Performing initial admission assessment for a patient with
chest pain.
C. Reinforcing teaching about a new warfarin prescription.
D. Assessing and documenting neurovascular status of a
splinted limb.
Correct Answer: D
Rationales:
• Correct (D): LPNs with appropriate competency can
perform focused ongoing assessments like neurovascular
checks and document findings under RN supervision.
• A: Administration through a newly placed feeding tube
requires RN knowledge for verification and potential
complications.
• B: Initial admission assessment including triage for chest
pain requires RN assessment/clinical judgment.
• C: Reinforcing new medication teaching is within RN scope
due to teaching complexity and medication safety.
Teaching Point: Delegate tasks based on scope, competency,
and patient complexity.
